Breast Cancer in a Wife, How Husbands Cope and How Well It Works

Silvia M. Bigatti, PhD; Linda F. Brown, MS; Jennifer L. Steiner, MS; Kathy D. Miller, MD 

DISCLOSURES

Cancer Nurs. 2011;34(3):193-201.

 

Abstract and Introduction

Abstract

Background: Husbands of patients with breast cancer (HBCs) experience as much as or even more distress than patients. Husbands' coping strategies may predict their level of distress.

Objective: The present study examined the coping strategies of HBCs compared with husbands of women without cancer (HWCs) and the relationship between coping and various psychosocial variables.

Methods: Psychosocial and physical health correlates of coping in both groups were assessed. Husbands of women with breast cancer (n = 83) and without breast cancer (n = 79) completed self-report questionnaires including the Ways of Coping Questionnaire, the Center for Epidemiological Studies Depression Scale, the Subjective Stress Scale, the Satisfaction With Life Scale, and the Locke-Wallace Marital Adjustment Test, in addition to measures of burden.

Results: The HBC and HWC groups were significantly different for 6 of the 8 coping styles assessed, with HBC using these strategies less than HWCs. Among HBCs, higher use of distancing, accepting responsibility, and escape-avoidance was associated with higher stress and symptoms of depression, and distancing and accepting responsibility were associated with lower marital satisfaction.

Conclusions: Results suggest that coping strategies may be different when dealing with cancer in a wife than at other times and that coping relates to well-being and is therefore worthy of focus.

Implications for Practice: Simple assessments of primary coping strategies may help clinicians identify HBCs in need of interventions. Husbands of women with breast cancer can be given problems to solve that will help them cope and help the patient and clinic staff as well. Interventions aimed at the couple, and not exclusively the HBC, may be particularly helpful.

Introduction

In the cancer care arena, increasing emphasis is being directed at attending to the psychosocial needs of patients and their families. Family members are sometimes considered "second-order patients," as high stress levels in caregivers can interfere with their ability to provide support to the cancer patient.[1] In this environment, husbands of breast cancer patients (HBCs) are receiving more and more attention from researchers as the negative impact of the cancer on their well-being is recognized. Distress among HBCs is as high as the patient's or higher,[2]because of the cancer. Compared with husbands of women without illness, HBCs report worse physical and mental health regardless of the severity of the cancer.[3] Wagner et al[3] found among HBCs that the coping style they used was related to overall quality of life.

Coping is an important variable to examine because it traditionally has been conceptualized as a mediator between a stressor (in this case, breast cancer in a wife) and outcome (physical or mental deterioration). As such, it exercises quite a bit of influence over whether the stressor will result in negative outcomes for any one individual.

Coping has been defined as "…constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person."[4]It can serve several functions. Coping may prevent a stressful situation, help manage the situation, manage the meaning of the situation, or manage the stress symptoms associated with the situation. Husbands of women with breast cancer will need to use their repertoire of coping skills to manage their involvement in the cancer patients' illness and care, manage the meaning of the chronic illness for their families, and manage the stress symptoms associated with it.[5]

To help manage the situation in the breast cancer context, HBCs may use problem-solving strategies to reduce the burden associated with the illness.[5] Lazarus and Folkman[4] characterized such strategies as problem-focused coping. For example, an HBC may actively participate in discussions with health care providers to ensure that effective medications are prescribed for the patient. Husbands of women with breast cancer also may use other forms of problem-focused coping to help manage their own stress associated with the patients' chronic illness, resulting in less negative outcomes.[5] These strategies tend to be directed at internal processes.[4] Common strategies include finding time to take care of one's own needs and the use of stress management techniques.

Another style of coping used by HBCs can be characterized as emotion focused.[4] The meaning HBCs attribute to their wives' illness and to their own role in helping the patient cope with it will determine how stressful it becomes for them.[5] Husbands of women with breast cancer who use coping strategies that make the situation seem less threatening, such as cognitive reappraisal, avoidance, or denial, may feel less stress/burden than those who view the patients' illness as unbearable. Emotion-focused coping may be used "…to maintain hope and optimism, to deny both fact and implication, to refuse to acknowledge the worst, to act as if what happened did not matter…."[4] Examples of such coping strategies are the use of humor and remembering the relationship before the onset of the breast cancer, rather than focusing on the possibility that increased deterioration of the patient will continue to occur.

Lazarus and Folkman[4] identify 3 possible ways in which coping can mediate the relationship between stress and poor health. First, coping influences neurochemical stress reactions. For example, research has shown that at different levels of perceived stress, coping is associated with different immune function responses.[6] Second, when coping efforts used to deal with stress are noxious to the individual, such as using drugs or alcohol, individuals' health may suffer. Finally, sometimes the use of emotion-focused coping, which may involve denial or avoidance, prevents the individual from searching for solutions to a solvable problem and, as a result, becomes a counterproductive style.

A small but important literature examines coping strategies among HBCs-typically within the context of the dyadic relationship. The usual approach is to compare HBCs coping with patient coping and examine the effects of one on the other. This literature suggests that HBCs use fewer coping strategies than their wives and that their coping is mostly problem focused,[7] although to a lesser degree than the patient's/wife's.[8]Findings from this literature support general coping research in that coping style is associated with psychological functioning. For example, Kershaw et al[9] found that avoidance coping in caregivers of breast cancer patients was associated with lower mental quality of life to a larger degree than any other strategy examined. Ptacek et al[7] found problem-focused coping to be associated with higher marital satisfaction and emotion-focused coping to be associated with lower marital satisfaction.

These findings are significant because HBC coping styles have been associated with outcomes in the wives/patients. Problem-focused coping in the HBCs has been associated with higher marital satisfaction in the wife/patient,[7] whereas emotion-focused coping in the HBCs is associated with distress in the patient.[8]

No reports have yet been published, however, that describe in detail the coping strategies of HBCs, especially when compared with husbands of women without illness. Such data would allow us to further understand to what extent HBCs draw on their coping resources in the context of their wives' breast cancer, whether such coping strategies are effective, and, if so, which work best. Comparing the coping of HBCs with that of husbands of women who are not ill will allow us to identify differences in coping strategies between the groups. The findings may also shed light on the significance of the research that explains the impact of HBC coping on patient outcomes, as it would provide us with a snapshot of whether their coping in this situation is similar to their general coping style or whether coping gets blunted or changed in some way that is unique to this stressor. Finally, a clear understanding of how coping in these men is different from coping in men without this stressor may suggest avenues for interventions aimed at maximizing coping resources for this population.

The purpose of the present study was to examine in detail the coping strategies used by HBCs and to compare their strategies with those of husbands whose wives are not ill. Psychosocial and physical health correlates of coping in both groups were also examined, as was the relation between HBC coping and wife/patient illness variables.

Methods

Participants

A total of 212 married or partnered men were recruited for the present study. Of the 101 HBCs recruited, 18 failed to return their questionnaires, leaving a final sample of 83 HBCs. Of the 110 husbands of women without chronic or acute illness recruited for the comparison group, 11 failed to return their questionnaires. Of the remaining 99 participants, 20 were younger than the youngest in the HBC group. These were dropped so that the groups would be matched on age, leaving a final sample of 79 husbands of women without illness.

 

Most husbands in the study were white (91.8%), with an average age of 50 (SD, 12.56) years. Most were college graduates (54%) and employed full-time (64.8%), and a significant proportion of participants (41.6%) earned an income of more than $70 000. There were no statistically significant differences by group on any of these variables. Table 1 presents the demographic data by group.

Wives with Breast Cancer

Descriptive information was provided on the wife's breast cancer because it is the factor that distinguishes the HBCs from the comparison husbands. The average time since diagnosis was 34 months (median, 15 months; mode, 4 months). Wives were at all stages of disease; specifically, 20% had stage I, 35% stage II, 20% stage III, and 17% stage IV. Eight percent of the husbands were not able to report stage of illness for their wives. Most wives had surgery (77% had either lumpectomy or mastectomy, and 14.5% had both), and most had started their adjuvant treatments (48.8% had either radiation, chemotherapy, or hormone therapy; 30.5% had 2 of these; and 18.3% had all 3). Most HBCs (83%) reported that their wives were currently affected by treatment adverse effects. The most commonly reported adverse effects were fatigue (46%), nausea (36%), pain (28%), and hair loss (23%). Only 36% of the wives who worked prior to the diagnosis continued to work without interruption; for the remainder, husbands reported either that their wives had work-related disability (29%), reduction in work hours (27%), or that they had stopped working completely (8%).

 

Procedure

Husbands of women with breast cancer were recruited through a regional cancer center after approval was granted by the center's Scientific Review Committee and the university institutional review board. Research assistants (RAs) approached HBCs in the chemotherapy infusion area before or during treatment. The RAs fully described the study to them, and those who consented were provided survey packets to complete at home and return via mail. No HBCs approached for participation refused, although 18% never returned their questionnaires.

 

Participants in the comparison group were recruited through campus advertisements and e-mails. The men in the comparison group were spouses of women who had never been diagnosed with breast cancer and who had no chronic or life-threatening illnesses. These husbands called the research office to provide informed consent before surveys were mailed to their homes. Husbands who failed to return their packets within 2 weeks received reminder telephone calls by trained RAs. Research assistants reviewed all returned surveys and called the participants to collect missing data. Once the surveys were returned, participants were sent $30 grocery gift certificates. Data were entered and double-checked by trained RAs.

 

Measures

Demographic Characteristics—Project Questionnaire This instrument was developed by project personnel and used to obtain demographic information and information on the patient's cancer and treatment.

 

Coping—Ways of Coping Questionnaire Coping strategies were measured using the Ways of Coping Questionnaire.[10] The measure has 66 items that assess the thoughts and actions of individuals as they cope. Items are grouped into 8 subscales-four of which make up the problem-focused coping scale and 4 make up the emotion-focused coping scale. The problem-focused subscales are planful problem solving, seeking social support, accepting responsibility, and confrontive coping. The emotion-focused coping scale is made up of positive reappraisal, escape-avoidance, distancing, and self-controlling. Higher scores indicate more frequent use of that coping style. Brief explanations of each subscale are presented in Table 2. The Ways of Coping Questionnaire has internal consistency reliabilities ranging from α = .61 to α = .79. Construct validity has been supported by consistency with theoretical predictions.[12]Internal consistency was estimated with the sample used for the present study and found to be α = .83 for emotion-focused coping and α = .84 for problem-focused coping.

Depression—Center for Epidemiological Studies Depression Scale The Center for Epidemiological Studies Depression Scale was designed to measure depressive symptoms, with an emphasis on depressed mood.[13] This 20-item self-report instrument has been used extensively in the health literature. Responses are given on a 4-point Likert-type scale (0 = rarely or none of the time to 3 = most or all of the time). The scale distinguishes between various levels of problem severity. Reliability has been reported at α = .88. Internal consistency was estimated with the sample used for the present study and found to be α = .89.

 

Subjective Stress Scale This short 4-item scale was developed by Chapman et al[14] for the Los Angeles Heart Study. Responses are chosen from a 4-point Likert-type scale (1 = this does not describe me at all to 4 = this describes me very well). Items in this scale have been found to correlate with social stress (r = 0.32) and neuroticism (r = 0.42).[15] Stress scores from the scale have been reported to be relatively stable over time.[16] Internal consistency was estimated with the sample used for the present study and found to be α = .83.

Satisfaction with Life Scale This short (5-item) instrument developed by Diener et al[17] is designed to measure quality of life from the point of view of the individual. Responses are given on a 7-point Likert-type scale (1 = strongly disagree to 7 = strongly agree). Internal consistency was reported by the authors at α = .87, test-retest reliability at α = .82, and concurrent validity as appropriate. Internal consistency was estimated with the sample used in the present study and found to be α = .88.

Marital Satisfaction—Locke-Wallace Marital Adjustment Test Created by Locke and Wallace,[18] this 15-item self-report instrument is widely used in the caregiver and chronic illness literature to measure marital adjustment. The authors report a split-half reliability of α = .90. The authors also claim good validity, with the instrument discriminating between adjusted and maladjusted couples. Internal consistency was estimated with the sample used for the present study and found to be α = .70.

Burden

Activities of Daily Living—Illness Impact Form. Designed by Gallo and reported in Sexton and Munro,[19] this instrument measures how much the patient depends on the spouse for activities of daily living (ADLs) and instrumental ADLs (IADLs). The measure was adapted for use with the specific population in the present study. It contains a list of ADLs and IADLs and asks how much the patient depends on the respondent for those activities on a 4-point Likert scale (0 = never, 1 = sometimes, 2 = most times, 3 = always) specifically because of the breast cancer. Internal consistency was estimated with a sample of husbands of patients with fibromyalgia and found to be α = .83.[20] Internal consistency in the present sample was α = .81.

Role Strains—Psychological Adjustment to Illness Scale. The self-report version developed for spouses of patients was used.[21] This 46-item measure assesses role strains and the psychological and social adjustment of spouses to illness. It includes 7 domains, of which 5 were used for the measurement of burden in the present study: vocational, domestic, and social environments and sexual and extended family relationships. Reliability coefficients range from a high of 0.87 for domestic environment to a low of 0.66 for extended family. The measure correlates highly with other measures of psychological adjustment to illness, such as Global Adjustment to Illness Scale (r = 0.81).[21] Internal consistency for the total of the 5 role strains in the present sample was α = .54.

Cancer Stage. Husbands of women with breast cancer were asked to report the stage of their wives' cancer.

Cancer Symptoms. Husbands of women with breast cancer were asked to report the symptoms of the cancer and treatment adverse effects experienced by their wives/partners.

Cancer Treatments Received. Husbands of women with breast cancer reported on the treatments received by their wives/partners, including type of surgery and type of adjuvant therapy.

Results

Burden of Breast Cancer for HBCs

Husbands of women with breast cancer were involved in providing care for their wives associated with the breast cancer in ADLs such as dressing (37%), eating (31%), bathing (21%), using the toilet (12%), and even walking in the house (7%). For IADLs, HBCs reported that because of the breast cancer they helped their wives with shopping (66%), trips outside (42%), taking medicine (46%), managing finances (49%), and organizing appointments (41%). Husbands of women with breast cancer reported varying amounts of role strain, with the highest being in the social environment, followed by sexual, vocational, domestic, and extended family relations.

 

Relationship Between Burden and Coping in HBCs

To better understand the relationship between the burden of breast cancer and the HBC coping style, we regressed each coping subscale on role strains, ADL, number of symptoms of chemotherapy experienced by wife, number of treatments (surgeries and adjuvant treatments) undergone by wife, and cancer stage.

 

The regressions for distancing, self-controlling, seeking social support, accepting responsibility, and positive reappraisal were not significant, suggesting no relationship between illness burden and these coping styles.

The regression for confrontive coping was significant, F 5,57 = 2.56, P = .037, and accounted for 18.3% of the variance. Only role-strain scores entered the regression equation (β = .333) and showed that higher confrontive coping was associated with higher role strains.

The regression for escape-avoidance was significant, F 5,57 = 3.48, P = .008, and accounted for 23.4% of the variance. None of the individual predictors accounted for significant proportions of variance.

The regression for planful problem solving was significant, F 5,57 = 2.95, P = .020, and accounted for 20.5% of the variance. Role strains (β = .305) and wife's cancer stage (β = −.332) entered the regression equation, with higher role strains and lower stage associated with higher use of planful problem solving.

Differences in Coping Between Groups

A multivariate analysis of variance was conducted to compare HBCs with the comparison group on the 8 subscales of the Ways of Coping Scale. The multivariate test was significant, F 8,146 = 9.441, P < .001, multivariate effect size = 0.341. Univariate follow-up tests showed that confrontive coping (partial ŋ2 = 0.054), distancing (partial ŋ2 = 0.030), self-controlling (partial ŋ2 = 0.058), seeking social support (partial ŋ2 = 0.112), accepting responsibility (partial ŋ2 = 0.157), and planful problem solving (partial ŋ2 = 0.137) differed significantly between groups (Table 3). For each of these coping styles, HBCs used the style less than comparison husbands. There were no differences between groups in escape-avoidance or positive reappraisal.

 

A second comparison was conducted examining groups by emotion-focused and problem-focused coping. The multivariate test was significant, F 2,152 = 21.56, P < .001, multivariate effect size = 0.221. Univariate follow-up tests showed problem-focused coping differed significantly between groups (partial ŋ2 = 0.196). Husbands of women with breast cancer used problem-focused coping less than comparison husbands; but emotion-focused coping did not differ (Table 3).

Paired-samples t tests were run to examine differences between emotion-focused and problem-focused coping within each group. For both groups, the differences between the 2 coping styles were statistically significant. Husbands of women with breast cancer, t 78 = 7.91, P < .001, and husbands of women without illness, t 75 = 2.33, P = .023, used emotion-focused coping more than problem-focused coping strategies.

Differences in Psychological Health of HBCs by Coping Style

In an effort to understand the relationships between the various coping styles and psychological health (satisfaction with life, subjective stress, depression, marital satisfaction) among HBCs (not comparisons), we compared HBCs who scored high on each subscale with those who scored low using multivariate analysis of variance. High versus low was determined by a median split of the scores for each subscale. There were no differences in psychological variables between HBCs by confrontive coping (high scores >5), seeking social support (high scores >7), self-controlling (high scores >10), or planful problem solving (high scores >9). Husbands of women with breast cancer who scored high (scores >6) on distancing reported worse psychological health than those who scored low, F 4,68 = 3.01, P = .024, ŋ2 = 0.150. Univariate follow-up tests showed that high distancing was associated with higher subjective stress (ŋ2 = 0.075), more symptoms of depression (ŋ2 = 0.071), and lower marital satisfaction (ŋ2 = 0.069) than was low distancing (Table 4).

 

Husbands of women with breast cancer who scored high (>4) on accepting responsibility reported worse psychological health than those who scored low, F 4,68 = 5.69, P = .001, ŋ2 = 0.251. Univariate follow-up tests showed that high accepting responsibility was associated with lower satisfaction with life (ŋ2 = 0.079), higher subjective stress (ŋ2 = 0.106), more symptoms of depression (ŋ2 = 0.158), and lower marital satisfaction (ŋ2 = 0.094) than low accepting responsibility (Table 4).

Husbands of women with breast cancer who scored high (>5) on escape-avoidance reported worse psychological health than those who scored low, F 4,68 = 3.28, P = .016, ŋ2 = 0.162. Univariate follow-up tests showed that high escape-avoidance was associated with higher subjective stress (ŋ2 = 0.099) and more symptoms of depression (ŋ2 = 0.129) than low escape-avoidance (Table 5).

Husbands of women with breast cancer differed on psychological health by their use of positive reappraisal, F 4,68 = 5.11, P = .001, ŋ2 = 0.231. Univariate follow-up tests showed that high positive reappraisal (>10) was associated with higher marital satisfaction (ŋ2 = 0.070) but also higher subjective stress (ŋ2 = 0.126) than low positive appraisal (Table 4).

Table 5 summarizes findings across groups and within HBCs for coping. The 2 main scales (problem- and emotion-focused coping) and the various subscales are represented in this table, which shows the significant relationships between coping and psychosocial factors and differences by group in coping style.

Discussion

We sought to develop a deeper understanding of coping among HBCs. Husbands of women with breast cancer in the present study were mostly white and educated and reported relatively high socioeconomic status. According to their own reports, a substantial proportion provided their wives with significant help in ADLs such as dressing and eating and instrumental ADLs such as shopping and taking medicine, because of the breast cancer. They also reported role strains associated with their wives' illness, with the highest in the social environment. This is not surprising because the majority of wives had undergone surgery for their breast cancer, and all but 2 had begun adjuvant (ie, radiation, chemotherapy) treatment.

 

Within the subscales of the Ways of Coping Questionnaire, HBCs used positive reappraisal most, followed by planful problem solving, self-controlling, seeking social support, distancing, confrontive, accepting responsibility, and, finally, escape-avoidance coping. These findings are partially consistent with previous research. Ptacek et al[7] used an earlier version of the Ways of Coping Questionnaire that had only 5 subscales, precluding the ability to make a direct comparison. They found that HBCs reported using problem-focused coping most and self-blame (comparable to our "accepting responsibility") least. Although our findings do not match those of the previous study entirely, they are not contradictory.

When we examined coping strategies further, we found that HBCs used emotion-focused coping strategies to a larger extent than they used problem-focused coping strategies. However, both HBCs and comparisons used emotion-focused coping more than problem-focused coping, so this difference is not unique to HBCs. Additionally, although both groups used emotion-focused coping more than problem-focused coping, our findings indicated that HBCs used problem-focused coping less than comparisons. Previous research has suggested that in situations in which the perceived potential for control over the stressor is higher, there is greater likelihood of using problem-focused coping as there is a higher chance of this strategy being effective in changing the outcome of the stressor.[4] It is possible that the HBCs used less problem-focused coping because of the limited potential for control in dealing with their partners' cancer. Under situations such as this, it is not surprising that problem-focused coping would be less prevalent in comparison to emotion-focused strategies and also in comparison to controls who may be coping with situations with greater potential for effective problem solving.

Of note is that the most- and least-used coping strategies (positive reappraisal and escape-avoidance, both emotion focused) were the only ones in which HBCs did not differ from husbands of women without illness. Previous research has suggested that men have certain patterns of coping with stressors within a marriage that are related to both their marital satisfaction and the satisfaction of their partner,[22] and this may be related to commonalities between groups despite the stressful situation. Bouchard and colleagues[22] found that individuals' use of denial as a coping style was associated with negative marital satisfaction for both themselves and their spouses and that distancing-avoidance was associated with their own negative satisfaction with the marriage. In that particular study, distancing-avoidance behaviors were described as "efforts to detach… and behavioral efforts to escape or avoid the problems,"[22] which is essentially the same strategy that what we have identified as escape-avoidance. It is possible that men in general practice escape-avoidance at lower rates because it leads to negative feelings and lower satisfaction on their part. This may provide some explanation for the low use of escape-avoidance in both groups.

Husbands of women with breast cancer reported using all other strategies less than comparison husbands. These findings may suggest a suppression of coping behaviors at the time of active treatment in the wife. Lazarus and Folkman[4] posited that either personal or environmental factors can lead to constraints to coping behaviors. Ptacek et al[7] compared the coping of patients with breast cancer with their husbands' coping and found that the patients reported more use of coping than did the husbands, a finding that seems to support the current findings of suppressed coping in these men. However, Ptacek et al,[7] as well as Ben-Zur et al,[8] found that HBCs in their samples used more problem-focused coping than emotion-focused coping, a finding different than our own. These inconsistent findings may be at least partially explained by differences in the samples. Our sample included patients in active treatment and with all stages of cancer (37% identified as stage III or IV), whereas the previous studies' samples were mostly limited to stages I and II breast cancer (100% in the Ben-Zur et al[8] sample and 86% in the Ptacek et al[8] study). In the study by Ptacek and colleagues,[7]patients had completed treatment an average of 15 months earlier. Many of our HBCs were in the throes of coping with the stress of their wives' active treatment and the concurrent adverse effects. More than a third were dealing with advanced stages of cancer, which may have been appraised as more of a threat. Problem-focused coping is less likely to occur, as noted earlier, when there is less potential for influencing a situation and also when the perceived threat is greater.[4] Excessive threat interferes with problem solving by affecting cognitive functioning and information processing. It is possible that higher degrees of perceived threat and lower perceived potential to influence the problem led to lower use of problem-focused coping in our sample.

We then focused exclusively on the HBCs and attempted to elucidate the relationships between coping and HBCs' mental health-their satisfaction with life, subjective stress, depression, and marital satisfaction. Our findings suggest that higher use of distancing, accepting responsibility (ie, self-blame), and escape-avoidance is associated with higher stress and more symptoms of depression than lower use. Higher use of distancing and accepting responsibility is also associated with lower marital satisfaction than lower use. Especially noteworthy is the difference in depression scores among those who score lower and higher in accepting responsibility, because lower users of accepting responsibility were within the reference range for the measure of depression (ie, nondepressed) and higher users of accepting responsibility scored within the depressed range. These findings are somewhat similar to those of Ptacek and colleagues,[7] who found that an HBC's use of avoidance and/or self-blame was negatively correlated with his marital satisfaction and mental health. Unfortunately, the cross-sectional nature of our data does not allow us to determine whether the coping causes the lower scores on these psychosocial measures or the lower scores on these measures lead to these types of coping, or even whether this is an interactional process. The literature provides sufficient evidence for both alternatives.[23,24]

Positive reappraisal, which is considered an adaptive emotion-focused coping style, was associated with higher marital satisfaction but also higher reported levels of subjective stress. Husbands who perceive higher levels of stress may add positive reappraisal to their coping repertoire in an effort to cope.

Because the factor that distinguishes HBCs from other husbands is the illness in the wife and its associated burden, we examined whether burden was associated with coping style. We conceptualized burden as wife illness characteristics (cancer stage, treatments received, and associated symptoms), wife need for assistance in ADLs, and HBC role strains. Burden was associated with the use of confrontive coping and planful problem solving through role strains and cancer stage; burden was also associated with escape-avoidance coping.

In summary, although HBCs showed restrained coping compared with husbands of women without illness, their various coping styles were related to a number of psychosocial and disease variables. The coping styles that were not related to any of these variables were seeking social support (a problem-focused style) and self-controlling (an emotion-focused style). Most, though, were related to negative psychosocial factors in HBCs (confrontive, accepting responsibility, planful problem solving, distancing, escape-avoidance, and positive reappraisals). Only positive reappraisal, the coping style used most by HBCs, had a positive association; HBCs with higher use of problem-focused coping reported higher marital satisfaction.

The main limitation of the present study is its cross-sectional design, which precludes conclusions about causal relationships. In all the relationships examined in this article, coping style may explain psychological factors, or psychological factors and disease variables may explain coping style. Moreover, a cross-sectional design does not allow the evaluation of changes in coping across time. Pearlin and colleagues[5] classify coping as fluid (ie, changing over time), especially when stressors are chronic. For HBCs, breast cancer may become a long-term stressor, and individuals may need to change and refine their coping repertoires to deal better with the stressor. Throughout the illness, coping may serve to mediate the effects of burden on HBCs' physical health. Husbands of women with breast cancer may try different coping styles throughout the breast cancer experience and determine that different styles are effective at different phases of the illness and its treatment. Future longitudinal research would add to our understanding of HBC coping with the breast cancer experience across time. Another limitation is the homogeneous demographic characteristics of these husbands. These findings cannot be assumed to generalize to men who have lower income or are nonwhite. Qualitative follow-up interviews might have clarified some of the questions that were elicited by our findings. Future research with mixed-methods designs may better determine the meaning of the relationships among variables found here.

Our findings have immediate implications for clinical practice. It is clear from the literature that husbands of patients need attention from clinical staff. Our findings suggest that targeting their coping style may help reduce their distress. A simple strategy for identifying husbands who may need help with coping would be to assess their primary coping style. A single question, such as "what are you doing to deal with her cancer (or treatment, surgery, symptoms, whatever may be most relevant)," may provide information useful to the clinician to identify effective or ineffective coping styles. Husbands who report using problematic coping styles, as identified in the present study, could be singled out for attention by clinic staff. Distressed husbands who report attempts to solve problems could be given tasks to do or problems to solve, such as implementing household schedules, managing patient medication, or keeping records of events and symptoms. Alternatively, clinic staff can work with both the husbands and patients. There are interventions aimed at coping specifically, such as Couples Coping Enhancement Training,[25]which have been found to reduce or prevent distress in couples. However, these have yet to be tried, in a modified format, for those facing the stress of cancer. Clinicians can also help husbands understand the important role they play during the cancer treatment. Research has shown that husbands, in fact, do problem solve at this time. They take on additional household chores and take care of patient and family needs that they may not usually be responsible for.[26] Making husbands aware of this and helping them reconceptualize these activities as coping efforts could result in better psychosocial outcomes.

A detailed understanding of coping strategies used by this population and the relationship with mental health is especially important because such knowledge may lead to the development and use of interventions aimed at helping these men. Typically, cancer care professionals strive to help patients and their families actively cope with breast cancer. However, without understanding the coping methods that HBCs use and their associated factors, these interventions will not be properly informed. The present study adds to our understanding the role of coping among this distressed population.

Source:

This project was funded by Walther Cancer Institute, Inc. Cancer Nurs. 2011;34(3):193-201. © 2011 Lippincott Williams & Wilkins